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DENTAL HISTORY
Patient Name
Preferred Name
Age
Referred by
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
Previous Dentist
How long have you been a patient?
Date of most recent dental exam
Date of most recent x-rays
Date of most recent treatment (other than a cleaning)
I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 mo.
Not Routinely
What is your immediate concern?
PLEASE ANSWER YES OR NO TO THE FOLLOWING
YES
NO
PERSONAL HISTORY
1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
2. Have you had an unfavorable dental experience?
3. Have you ever had complications from past dental treatment?
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
6. Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?
GUM AND BONE
7. Do your gums bleed or are they painful when brushing or flossing?
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
9. Have you ever noticed an unpleasant taste or odor in your mouth?
10. Is there anyone with a history of periodontal disease in your family?
11. Have you ever experienced gum recession?
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
13. Have you experienced a burning sensation in your mouth not related to your teeth?
TOOTH STRUCTURE
14. Have you had any cavities within the past 3 years?
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
18. Do you have grooves or notches on your teeth near the gum line?
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
20. Do you frequently get food caught between any teeth?
BITE AND JAW JOINT
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
22. Do you feel like your lower jaw is being pushed back when you bite your back teeth together?
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
24. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?
25. Are your teeth becoming more crooked, crowded or overlapped?
26. Are your teeth developing spaces or becoming more loose?
27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
28. Do you place your tongue between your teeth or close your teeth against your tongue?
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
30. Do you clench or grind your teeth together in the daytime or make them sore?
31. Do you have problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
32. Do you wear or have you ever worn a bite appliance?
SMILE CHARACTERISTICS
33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
34. Have you ever whitened (bleached) your teeth?
35. Have you felt uncomfortable or self-conscious about the appearance of your teeth?
36. Have you been disappointed with the appearance of previous dental work?
Patient's Signature
Date
Doctor's Signature
Date
Please fill out completely as possible. When submitting online, please type Patient's Name in the signature field above. Submission of this form is same as signing this form.
